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Crisis Point of Entry

Reporting

Settlement Agreement Provision

III.C.6.a.i – iii

The Commonwealth shall develop a statewide crisis system for individuals with intellectual and developmental disabilities. The crisis system shall:

                             i.        Provide timely and accessible support to individuals with intellectual and developmental disabilities who are experiencing crises, including crises due to behavioral or psychiatric issues, and to their families;

                            ii.        Provide services focused on crisis prevention and proactive planning to avoid potential crises; and

                            iii.        Provide in-home and community-based crisis services that are directed at resolving crises and preventing the removal of the individual from his or her current placement whenever practicable.

III.C.6.b.i

The crisis system shall include the following components:

i. Crisis Point of Entry

A.   The Commonwealth shall utilize existing CSB Emergency Services, including existing CSB hotlines, for individuals to access information about and referrals to local resources. Such hotlines shall be operated 24 hours per day, 7 days per week and staffed with clinical professionals who are able to assess crises by phone and assist the caller in identifying and connecting with local services. Where necessary, the crisis hotline will dispatch at least one mobile crisis team member who is adequately trained to address the crisis.

B.   By June 30, 2012, the Commonwealth shall train CSB Emergency Services personnel in each Health Planning Region (“Region”) on the new crisis response system it is establishing, how to make referrals, and the resources that are available.

Reports

Compliance Indicators

Compliance Indicators III.C.6.a.i-iii

Overall note: There are 3 main components: Prevention, Mobile Crisis, and Crisis Stabilization.

PREVENTION:

Prevention of crisis breaks into 4 sub-components:

1) Early identification

2) Assessment in home

3) Behavior supports in home

4) Availability of direct support professionals

Early Identification; and 2. Assessment in Home

DBHDS will add a provision to the CSB Performance Contract requiring CSBs to identify children and adults who are at risk for crisis through a screening at intake, and if the individual is identified as at risk for crisis needs, refer the individual to REACH to ensure that when needed the initial crisis assessments are conducted in the home.

DBHDS will add a provision to the CSB Performance Contract requiring, for individuals who receive ongoing case management, the CSB case manager to assess an individual’s risk for crisis during face to face visits and refer to REACH when a need is identified.

DHBDS will establish criteria for use by CSBs to determine “risk of hospitalization” as the basis for making requests for crisis risk assessments.

DBHDS will ensure that all CSB Executive Directors, Developmental Disability Directors, case management supervisors, and case managers receive training on how to identify children and adults receiving active case management who are at risk for going into crisis. Training will also be made available to intake workers at CSBs on how to identify children and adults presenting for intake who are at risk for going into crisis and how to arrange for crisis risk assessments to occur in the home or link them to REACH crisis services. DBHDS will add a provision to the CSB Performance Contract requiring training on identifying risk of crisis for case managers and intake workers within 6 months of hire.

DBHDS will implement a quality review process conducted initially at six months, and annually thereafter, that measures the performance of CSBs in identifying individuals who are at risk of crisis and in referring to REACH where indicated.

86% of children and adults who are known to the system will receive REACH crisis assessments at home, the residential setting, or other community setting (non-hospital/CSB location).

The Commonwealth will provide a directive and training to state-operated psychiatric hospitals to require notification of CSBs and case managers whenever there is a request for an admission for a person with a DD Diagnosis. Via the morning reporting process, the Director of Community Support Services or designee will notify the REACH Director or designee of admission for follow up. DBHDS will request and encourage private psychiatric hospitals to notify the emergency services staff of the CSB serving the jurisdiction where the individual resides of requests for admissions and admissions of individuals with a DD diagnosis.

The Commonwealth will track admissions to state-operated psychiatric hospitals and those to private hospitals as it is made aware, to determine whether there has been a referral to REACH and will implement a review process to determine if improvement strategies are indicated.

95% of children and adults admitted to state-operated and private psychiatric hospitals who are known to the CSB will be referred promptly (within 72 hours of admission) to REACH.

3. Behavior Supports In Home

By June 2019, DBHDS will increase the number of Positive Behavior Support Facilitators and Licensed Behavior Analysts by 30% over the July 2015 baseline and reassess need by conducting a gap analysis and setting targets and dates to increase the number of consultants needed so that 86% of individuals whose Individualized Services Plan identify Therapeutic Consultation (behavioral support) service as a need are referred for the service (and a provider is identified) within 30 days that the need is identified.

The Commonwealth will provide practice guidelines for behavior consultants on the minimum elements that constitute an adequately designed behavioral program, the use of positive behavior support practices, trauma informed care, and person-centered practices.

The Commonwealth will provide the practice guidelines and a training program for case managers regarding the minimum elements that constitute an adequately designed behavioral program and what can be observed to determine whether the plan is appropriately implemented.

The permanent DD waiver regulations will include expectations for behavioral programming and the structure of behavioral plans.

Within one year of the effective date of the permanent DD Waiver regulations, 86% of those identified as in need of the Therapeutic Consultation service (behavioral supports) are referred for the service (and a provider is identified) within 30 days.

86% of individuals authorized for Therapeutic Consultation Services (behavioral supports) receive, in accordance with the time frames set forth in the DD Waiver Regulations, A) a functional behavior assessment; B) a plan for supports; C) training of family members and providers providing care to the individual in implementing the plan for supports; and D) monitoring of the plan for supports that includes data review and plan revision as necessary until the Personal Support Team determines that the Therapeutic Consultation Service is no longer needed.

DBHDS will implement a quality review and improvement process that tracks authorization for therapeutic consultation services provided by behavior consultants and assesses:

1)   the number of children and adults with an identified need for Therapeutic Consultation (behavioral supports) in the ISP assessments as compared to the number of children and adults receiving the service;

2)   from among known hospitalized children and adults, the number who have not received services to determine whether more of these individuals could have been diverted if the appropriate community resources, including sufficient CTHs were available;

3)   for those who received appropriate behavioral services and are also connected to REACH, determine the reason for hospitalization despite the services;

4)   whether behavioral services are adhering to the practice guidelines issued by DBHDS; and 5) whether Case Managers are assessing whether behavioral programming is appropriately implemented.

4. Availability of Direct Support Professionals

1. DBHDS will implement a quality review process for children and adults with identified significant behavior support needs (Support Level 7) living at home with family that tracks the need for in-home and personal care services in their homes. DBHDS will track the following in its waiver management system (WaMS):

a.    The number of children and adults in Support Level 7 identified through their ISPs in need of in-home or personal care services;

b.    The number of children and adults in Support Level 7 receiving the in-home or personal care services identified in their ISPs; and

c.    A comparison of the hours identified as needed in ISPs to the hours authorized.

2. Semi-annually, DBHDS will review a statistically significant sample of those children and adults with identified significant behavior support needs (Support Level 7) living at home with family. DBHDS will review the data collected in 1.a-c and directly contact the families of individuals in the sample to ascertain:

a.    If the individuals received the services authorized;

b.    What reasons authorized services were not delivered; and

c.    If there are any unmet needs that are leading to safety risks.

Based on results of this review, DBHDS will make determinations to enhance and improve service delivery to children and adults with identified significant behavior support needs (Support Level 7) in need of in-home and personal care services.

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